YOU’VE PROBABLY HEARD OF OUR PRODUCTS
Women's health
GI
Other (incl. cardiovascular)
Anti-infectives
Aesthetics & dermatology
Eye care
Urology
Central nervous system
HOW WE GOT HERELEARNING OBJECTIVES
1. Introduce Human and Organizational Performance
concepts relating to SIF prevention
Create a paradigm shift in thinking about Safety
2. Demonstrate how HOP Theory has influenced these
EHS programs at Allergan
R2P
4
Safety is not the
absence of accidents.
Safety is the presence
of defenses.
ORCHSE Strategies, LLC Copyright 2015
IS ZERO THE RIGHT TARGET?
Zero as a metric literally measures nothing and you can’t
prevent failure based on knowing nothing
Todd Conklin
8
Herbert William Heinrich, Industrial Accident Prevention, A Scientific Approach, 1931
1
10
30
600
THE HEINRICH PYRAMID
Near Misses
Minor Injuries
Serious Injuries
Fatalities
IS THE HEINRICH PYRAMID CORRECT?The lower the incident rate, the higher the fatality rate
• State DART rate vs. fatalities graphic
–2013 RAND Study Am J Ind Med
• Corroborating Studies
–Finnish Construction and manufacturing study 1977-1991
–Aviation passenger mortality risk 2000
–Occupational Injury Statistics in Korea 2011• Injury rate 1/5 EU rate fatality rate 5 x’s EUs
Disasters don’t happen because someone drops a pipe on his foot or bumps his head.
They result from flawed ways of doing business that allow risks to accumulate.
(Elkind and Whitford 2011, p. 7)
The difference between a safe and unsafe organization lies not in how many incidents it has,
but in how it deals with the incidents that it has people report.
Sidney Dekker
IS ZERO THE RIGHT TARGET?
HUMAN AND ORGANIZATIONAL PERFORMANCE
HOP seeks to understand how
humans perform in complex
organizational systems so we can
build system defenses that are
more error tolerant
Organization Systems
People
Culture
ERROR TOLERANCEIf we focus on preventing human error, we design ideal systems that assume successful outcomes but typically fail when errors occur
OR
Do we design systems that assume errors will occur but still typically result in successful outcomes
Focus on Systems
14
KEY PRINCIPLES OFHUMAN & ORGANIZATIONAL PERFORMANCE
1. People are fallible, and even the best make mistakes
2. Error-likely situations are predictable, manageable, and preventable.
3. Individual behavior is influenced by organizational processes and values
4. Management’s response to failure matters
5. The way to prevent incidents is by learning
ORCHSE Strategies, LLC Copyright 2015
PEOPLE ARE FALLIBLE AND EVEN THE BEST MAKE MISTAKES:
How many times does the uppercase or lowercase letter“F”appear in the following sentence?
March 2015 ORCHSE Strategies, LLC Copyright 2015
Finished files are the re-
sult of years of scientific
study combined with the
experience of many years.
Finished files are the re-
sult of years of scientific
study combined with the
experience of many years.
HUMAN LIMITATIONS
“Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness.”
-Edward de Bono PhD
ORCHSE Strategies, LLC Copyright 2015
THE FAST BRAIN AND THE SLOW BRAIN
What if these brain-centered hazards are exacerbated by the fact that critical organizational elements—including work environments, technological interfaces, operating procedures, work schedules and even work cultures—are not aligned with how the human brain actually works?
Susan L. Koen, Ph.D.
19
Slow Brain – Analytical thoughtful actions
Fast Brain – “habitual/reactive/without thinking”
Our actions are primarily directed by the fast
brain
CINCINNATI ZOO GORILLA/TODDLER INCIDENT, MAY 28, 2016
Should we blame the mother for not paying enough attention to her child?
Cincinnati gorilla
incident: Police
investigating
boy's familyBy Dominique Dodley, Sarah Jorgensen
and Steve Visser CNN
Updated 3:14 PM ET, Thu June 2, 2016
CINCINNATI ZOO GORILLA INCIDENT MAY 28, 2016
Or should we make sure the next distracted mother doesn’t have the same outcome?
LEARNING OBJECTIVES
1. Introduce key concepts concerning Human and
Organizational Performance
Create a paradigm shift in thinking about Safety
2. Demonstrate how HOP Theory has influenced EHS
programs at Allergan
R2P
23
Good Observation Program
GM Weekly Safety Walk-Throughs
CAPA Council
Critical Safety Rules
Pre/Post-shift Musters and Critical Task(s) of the Day
EHS Alerts and Communication
Risk Maps
Safety in the 21st Century
Human Performance Influenced EHS Programs
WHAT ARE GOOD OBSERVATIONS?
Definition
• Documented employee observations that help prevent accidents from occurring. (EHS or management observations are excluded). Good observations may include near misses, unsafe acts or conditions and risk reduction suggestions.
Goals
• Provide a mechanism for employees to provide management their knowledge
• Find and fix things before incidents occur
• Continually focus on risk reduction
The difference between a safe and unsafe organization lies not in how many incidents it has,
but in how it deals with the incidents that it has people report.
Sidney Dekker
WHY GOOD OBSERVATIONS MATTER
Started as a metric
Value recognized quickly
Learning Culture
Sets expectations
Facilitates Positive Incentive Program
Becoming an expectation
GOOD OBSERVATIONS
0
20
40
60
80
100
120
140
160
180
200
2012 2013 2014 2015 2016 2017 YTD
Actavis and Allergan Operations Good Observation Rates 2012 - YTD
Leadership matters…
“The day soldiers stop bringing you their
problems is the day you have stopped leading
them. They have either lost confidence that
you can help or concluded you do not care.
Either case is a failure of leadership.”
Colin Powell
HYPOTHESIS: GOOD OBSERVATION RATES ARE CORRELATED WITH INJURY RATE REDUCTIONDATA FOR SIGNIFICANCE TESTING
THEREFORE:
According to percentage points of the chi square distribution table (Table 6) published in Rosner’s Fundamentals of Biostatistics 2nd Edition 1986,
We are scientifically certain (greater than 95% confident) that this relationship between Good Observation Rates and TRIR is not due to chance. In other words,
We are scientifically certain that strong Good Observation rates are associated with improving Total Recordable Injury Rates.
ENTERPRISE JAN 2016: LEADERSHIP AND EMPLOYEE ENGAGEMENT RELATIONSHIP TO INJURY RATES FREQUENCY AND SEVERITY
ENTERPRISE 2016 FEB YTD: LEADERSHIP AND EMPLOYEE ENGAGEMENT RELATIONSHIP TO INJURY RATES FREQUENCY AND SEVERITY
ENTERPRISE 2016 FEB YTD: LEADERSHIP AND EMPLOYEE ENGAGEMENT RELATIONSHIP TO INJURY RATES FREQUENCY AND SEVERITY
THE SEVEN DELUSIONS OF NEAR-ZERO ORGANIZATIONS
Corrie Pitzer, CEO SafeMap
Safety performance in many companies and even whole industries has stalled in the past few
years. Accidents rates are at a “plateau” and yet, serious accidents and fatality rates are not. In
more dramatic cases, such as in the BP Deepwater oil disaster, organizations that have
“exemplary” safety statistics, suddenly have a catastrophic or multi-fatality event. Are there
common features in these organizations’ mindset? What characterizes these organizations’
decision-making, their approach to safety and to risk and are there specific cultural features that
can be delineated?
The reason your TRIR is so low is not simply because of employee engagement nor your high rate of
CAPA closure (find-and-fix), but because you’ve convinced your employees to constantly look for
hazards, unsafe conditions or actions to report per your Good Observation program. They’re simply
more risk-aware and cognizant of their environment.
In other words, you’re coaxing them into a state of hyper-vigilance.
GOOD OBSERVATIONS AND LEADERSHIP LEADING SAFETY
“…I want to thank you for participating in the “GO” program, your GO’s are certainly worthy of winning but almost more importantly it is people like you that are driving this program forward and keeping the safety awareness high at our facility.
I believe that this program is the single biggest factor keeping people safe at the site.
If you think about it, if only the EHS team were actively involved in making the site safer, there is a real limit to how much they can get to observe and react to on a monthly basis. With the GO program, we have over 700 people having the ability to catch an issue before someone gets hurt.
Thank you again for your great GO’s and helping keep all of us safe.”
Dermot Manton – VP, GM Waco - 2017
Good Observation Program
GM Weekly Safety Walk-Throughs
CAPA Council
Critical Safety Rules
Pre/Post-shift Musters and Critical Task(s) of the Day
EHS Alerts and Communication
Risk Maps
Safety in the 21st Century
Human Performance Influenced EHS Programs
CRITICAL SAFETY RULES PRE-SHIFT MUSTERS
PURPOSE
2.1 Consider risk reduction measures that eliminate conditions that have a potential for a Serious Injury or Fatality (SIF) i.e., tasks that involve a Critical Safety Rule.
2.2 Prevent potential SIFs by conducting pre-shift risk assessments which address the two precursors of almost every fatal accident:
(1) There is sufficient energy in the process to kill
(2) The worker is often unaware of the critical risk i.e., they’ve become complacent.
Pre-shift risk assessments can prevent most, if not all, workplace fatalities by preventing complacency, ensuring the risks are well understood and that all precautions have been taken.
THE FAST BRAIN AND THE SLOW BRAIN
What if these brain-centered hazards are exacerbated by the fact that critical organizational elements—including work environments, technological interfaces, operating procedures, work schedules and even work cultures—are not aligned with how the human brain actually works?
Susan L. Koen, Ph.D.
45
Slow Brain – Analytical thoughtful actions
Fast Brain – “habitual/reactive/without thinking”
Our actions are primarily directed by the fast
brain
THREE QUESTIONS TO PREVENT SIF’S
1.What task could cause immediate, non-recoverable harm to people or the facility?
2.What should we do to ensure this task for this work at this time is successful?
3.When this task fails, what is it that keeps you from being killed or seriously injured? Is that enough?
Todd Conklin, Ph.D.
Rushing
High workload
Unclear labeling
Inaccurate procedures
Unexpected conditions
Stress
Do any of these conditions exist?Error Traps and Error-Likely Situations
PRE-SHIFT MUSTER DISCUSSIONS DEFEAT COMPLACENCY
Do any of our planned tasks today involve a critical safety rule?
Agree on Stop Work Criteria.Discuss precise criteria before shift begins
Write them down and agree upon them
This in addition to Critical Tasks of the Day
Unclear expectations
Multi-tasking
Interrupted work
Work-arounds
New technique
1st time performing task
Double Shift / Fatigue
Discuss the Critical Control Consult the Supervisor prior to initiating the task
Tools available to facilitate this process
SPEAK – Pre-shift and CLEAR – Post Shift
Start When Sure
DO WE HAVE TO WORK
ANYWHERE TODAY
ABOVE SIX FEET FROM
THE GROUND?
ARE THERE RAILINGS IN
PLACE?
DO YOU HAVE TO CARRY
ANYTHING UP OR DOWN?
WHAT PRECAUTIONS
WILL YOU TAKE?
COME GET ME BEFORE
YOU DO THIS. OKAY?
ARE WE HANDLING
ANY FLAMMABLE
SOLVENTS OR
REACTIVE
CHEMICALS TODAY
IN ANY OF OUR
PROCESS STEPS?
WHAT CONTROLS
ARE IN PLACE TO
PREVENT A FIRE, AN
EXOTHERMIC RXN
OR EXPLOSION?
Stop Work Criteria?
PRE-SHIFT MUSTER EXAMPLE
The difference between a safe and unsafe organization lies not in how many incidents it has,
but in how it deals with the incidents that it has people report.
Sidney Dekker
IN CONCLUSION